We estimate that it will take about 45 minutes to read. Send or bring this completed report to your local Social Security office. OMB No. Please tell us if you want us to return them to you. Form . Please print, type, or write clearly and answer all items to the … If your application is denied and you wish to continue trying to get SSD benefits, then you must fill out Form SSA-3441, along with any other required documents. If you have more than three providers, list them in SECTION 10 - REMARKS on the last page. It is required if you are initially denied benefits and you want to appeal the decision. Form SSA-3441-BK Relationship to Disabled Person DaytimeMailing Address (Street or PO Box) Include apartment number or unit if applicable.Who is completing this form?Name (First, Middle, Last) Phone Number, including area code (include IDD and country codes if … If you do not wish to appeal a "non-medical" decision online, you can use the Form SSA-561, Request for Reconsideration. SSA-3441-BK (Disability Report - Appeal) Skip to content. Please note that the Disability Report - Appeal (form SSA-3441-BK) has replaced the old “Claimant’s Statement When Request for Hearing is Filed and the Issue is Disability.” To save files, right click and choose 'Save Target As' or 'Save Link As' File Attachment: Attachment Size; ssa_501_Request_for_ALJ_hearing.pdf: 84.55 KB : ssa-3441.pdf: 202.57 KB: 8145_ssa-827.pdf: 110.57 … FormSSA-3441-BK (08-2010) ef(08-2010) SECTION 10 - REMARKS Use this section for any additional information you did not show in earlier parts of this form. If you need more space to answer any question, please use the REMARKS section on the last. However, we may use it for the administration and integrity of Social Security programs. What is SSA Form 3441? Form SSA-3441, Disability Report - Appeal, and; Form SSA-827, Authorization to Disclose Information to the Social Security Administration. It is entitled the “Disability Report – Appeal” form and it is required for any applicant who wishes to continue seeking SSD benefits through the appeal process . The Disability Report – Appeal is an update. If a phone number is outside the. 0960-0144 For SSA use only. Show details. If You Disagree With A Non-Medical Decision. _____________________________________________________________________, Date(s) attended: _____________________________________________________________________. Use the following pages to provide information for up to three (3) providers. This page is for requesting a hearing. We, may also disclose information to another person or to another agency in accordance with approved. and have it with you for your appointment. Are you currently taking any medicines (prescription or non-prescription)? Official website of the U.S. Social Security Administration. Someone else (Please complete the information below). you provide to update your disability report information. Please do not write in this box. It is also known as the “Disability Report ― Appeal.” The form requests updated information regarding your medical condition, including new treatments, tests, procedures, doctors, hospitals, and medicines. If you have any questions, you may call us toll-free at 1-800-772-1213 Monday through Friday from 7 a.m. to 7 p.m. helps us process your claim. FORM SSA-3441-BK (1-2005) ef (12-2005) Use 2-2004 Edition Until Supply Is Exhausted PAGE 1 Approximate date the changes occurred: Month Day Year B. Since you last told us about your medical conditions. Print the Form. Mailing Address (Street or PO Box) Include apartment number or unit if applicable. Form SSA-3881-BK (02-2015) ef (02-2015) Use (12-2013) ef (12-2013) edition until exhausted. A. Only list the providers you have seen since you last told us about your medical treatment. Check this box if you do not have a phone number where we can leave a message. If no, what language does the contact person prefer? If you receive a Benefit Verification letter, sometimes called a “budget letter,” a “benefits letter,” a “proof of income letter,” or a … AFTER COMPLETING THIS REPORT, REMOVE THIS SHEET AND KEEP IT. You can write "don't. The person listed in 2.A. Our offices are also listed under U.S. Government agencies in your telephone directory or you may call When you’re appealing, you’ll need to update your disability case file with medical treatment received since the date you filed your initial application. FormSSA-3441-BK (08-2010) ef(08-2010) PAGE7. If you are deaf or hard of hearing, you may call our TTY number, 1-800-325-0778. If you are having an interview in our, office, bring your medical records, your prescription medicine containers (if available), and this completed. If you need more space, use SECTION 10 – REMARKS on the last page. Include the number of the question you are answering. give us on this report tells us where to request your medical and other records. If you do not agree with our decision, you can appeal—that is, ask us to look at your case again. Form SSA-3881. Send ONLY comments relating to our time estimate to this address, not the completed form. Completing this report accurately. the instructions, gather the facts, and answer the questions. Phone Number, including area code (include IDD and country codes if outside the U.S. or Canada), another number where we may reach you, if any, Daytime Phone Number, including area code (include IDD and country codes if outside the U.S. or Canada). Tricky Questions on Appeal Forms (SSA-3441) Art: Robin Mead. ssa 3441. 3. QUESTIONNAIRE FOR CHILDREN CLAIMING SSI BENEFITS. Page 2 of 10. 405 (a) and (b)), 223 (42 U.S.C. . You may request an appeal online for a "non-medical" decision. have you completed or are you enrolled in any type of. Date when you started participating in the plan or program: Use this space to provide any information you could not show in earlier sections of this form or any additional, information you feel we should know about. routine uses, which include but are not limited to the following: 1. STATEMENT OF CLAIMANT OR OTHER PERSON. After you receive a denial letter from the SSA giving the reason why you were denied, Form SSA-3441 is a crucial part of filing your appeal. B. You can find the form here. 85 check-boxes. You must submit the form before the SSA’s deadline, or you risk having to start over from the beginning with your application. One of these two forms (the letter you received from us should tell you whether you should request a reconsideration or a hearing). 8. Send the completed form to your local Social Security office. If you have new information that may strengthen your case, the information provide on Form 3441 may tip the scales in your favor. Mental (including emotional or learning problems). 423 (d)), and 1631 (42 U.S.C. Has this provider performed or sent you to any tests? Download a copy of the form SSA-3441-BK here. Form SSA-795. Since you last told us about your medical treatment, provider, received treatment at a hospital or clinic, or. information, put and request legally-binding digital signatures. No need to stress over your appeal forms. Provide complete phone numbers, including area code. If you are filling out this report for someone else, refers to “you” or “your,” it refers to the person who is applying for disability benefits, SECTION 1 – INFORMATION ABOUT THE DISABLED PERSON. If yes, you will be asked to provide additional information. 1. To make determinations for eligibility in similar health and income maintenance programs at the, 4. If you do not wish to appeal online, you should submit: Form SSA-561, Request for Reconsideration, if you are requesting a reconsideration of your claim; OR. Form SSA-3441 | Disability Report - Appeal. Don’t delay starting your appeal. If you have Internet access, you, can locate your nearest Social Security office by zip code at, are also listed under U.S. Government agencies in your telephone directory or you may call Social. If you have been treated by more providers, use section 10 - REMARKS on the last page. If you cannot remember the names and addresses of your health care providers, you may be, able to get that information from the telephone book, Internet, medical bills, prescriptions, or. 3. ssa 3441 2015-2020. Edit & Download Download . Please be sure to include the number of the question you are answering, By logging in, you indicate that you have read and agree our, unless this report indicates otherwise. Name of Wage Earner, Self-employed Person, or SSI Claimant. Authorization to Disclose Information to the Social Security Administration, Request for Hearing by Administrative Law Judge, Your Right to Question The Decision Made On Your Claim, Your Right to Question A Decision Made On Your Supplemental Security Income (SSI) Claim, Your Right To Question The Decision To Stop Your Disability Benefits. If you make an appointment with us, please complete as much of this report as you can. DISABILITY REPORT – APPEAL Page 1. know," or "none," or "does not apply" if you need to. ssa 3441. Social Security Administration. Additional information about these and other system of records notices and our, We may also use the information you provide in computer matching programs. Form SSA-3441-BK (08-2010) ef (08-2010) Destroy Prior Editions SOCIAL SECURITY ADMINISTRATION DISABILITY REPORT - APPEAL Form Approved OMB No. B. If you have any medical records that you have not given to us, send or bring them to our office with this, completed report. If you have Internet access, you may be able to complete this report online at. When we make a decision on your claim, we send you a letter explaining our decision. Program Operations Manual System (POMS) Effective Dates: 06/26/2020 - Present Previous | Next. an individual work plan with an employment network under the Ticket to Work Program? 1383 (e)(1)) of, the Social Security Act, as amended, authorize us to collect this information. TN 5 (06-20) DI 12095.030 SSA-3441-BK (Disability Report - Appeal) A. This form is part of the appeal process and helps your DDS examiner know where you are going to the doctor, the medications you take and information about how you are feeling. A. On average this form takes 66 minutes to complete. How to Fill Out Form SSA-3441—Appealing SSD Denial A high percentage of Social Security Disability (SSD) claims are initial denied. The person who is applying for disability (Go to SECTION 3 - MEDICAL CONDITIONS). specialized job training, trade school, or vocational school? Collection and Use of Personal Information, Sections 205 (42 U.S.C. R continuing disability determination or evaluating any request for a hearing. For SSA use only. Please do not write in this box. Form Approved . , please provide information about him or her. (e.g., to the Government Accountability Office and Department of Veterans Affairs); 3. All forms are printable and downloadable. Security at 1-800-772-1213 (TTY 1-800-325-0778). OMB No. DISABILITY REPORT - APPEAL - Form SSA-3441-BK READ ALL OF THIS INFORMATION BEFORE YOU BEGIN COMPLETING THIS FORM We will use the information that you give us on this form to update your disability report information for your appeal. The form specifically asks about any changes in your medical condition, new limitations, and new treatment since you filed the last a disability report. 7. Since you last told us about your education, If yes, what type? 0960-0144 PAGE 1 For SSA Use Only Do not write in this box. Include a ZIP or postal code with each address. (Go to SECTION 3 - MEDICAL CONDITIONS). If you do not have any more providers to describe. conditions (including emotional or learning problems). such as a friend or family member. Having trouble downloading PDF files or with the PDF editor. If you need to list more tests, use SECTION 10 - REMARKS on the last page. United States, also provide International Direct Dialing (IDD) code and country code. page, SECTION 10. Form SSA-3441-BK DISABILITY REPORT - APPEAL. If your application is denied and you wish to continue trying to get SSD benefits, then you must fill out Form SSA-3441, along with any other required documents. It may seem repetitive, but the more effort you invest, the stronger your form and appeal will likely be. Furnishing us this information is voluntary. Social Security Administration. any program providing vocational rehabilitation, employment services, or other support services to help, SECTION 9 – VOCATIONAL REHABILITATION, EMPLOYMENT, OR OTHER SUPPORT SERVICES. an individualized plan for employment with a vocational rehabilitation agency or any other organization? What medical conditions were treated or evaluated? Get Form. Link to the current form SSA-3441-BK To view the current version, go to SSA-3441–BK. B. Since you last told us about your vocational rehabilitation, h. ave you participated, or are you participating in: Access your account to see all saved docs. You must enable session cookies in your browser to use this service. Fillable Printable Form SSA-795. Since you last told us about your medical conditions. Information, from these matching programs can be used to establish or verify a person's eligibility for Federally funded, or administered benefit programs and for repayment of payments or delinquent debts under these, This information collection meets the requirements of 44 U.S.C. Get . B. Many forms must be completed only by a Social Security Representative. The form you are looking for is not available online. 5. Appeal forms are just a way to get the process started. PLEASE READ THIS INFORMATION BEFORE COMPLETING THIS REPORT, This report is used to update your information for your disability appeal. If you need to list more medicines, use SECTION 10 – REMARKS on the last page. (approximate date, if exact date is unknown), Yes (Please complete the information below.). If you cannot complete this report, a Social Security representative, can assist you. Social Security Search Menu Languages Sign in / up. Examples are maiden name, , have you seen a doctor or other health care, do you have a future appointment scheduled. Form SSA-3441-BK (03-2015) ef (03-2015) Destroy Prior Editions SOCIAL SECURITY ADMINISTRATION. It will be a long time before your hearing, so you will have plenty of time to keep sending them new information. SSA-3441-BK (11-2020) UF. ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROVIDER ABOVE. Please complete as much of this report as you can. hospitals (including emergency room visits). Turn them into templates for numerous use, include fillable fields to gather recipients? Name of Person Making Statement (If … Form SSA-3441-BK, Disability Report - Appeal is a form used for all reconsideration and hearings appeal requests concerning disability issues. Fillable Printable Form SSA-3881. This website is produced and published at U.S. taxpayer expense. Send or bring this completed report to your local Social Security office. The Social Security Administration (SSA) has a strict deadline for appeals. Edit & Download Download . Check out now! The SSA-3441 is a form that’s only required if you’re initially denied Social Security Disability (SSD) benefits and need to appeal the decision. go to SECTION 5 – OTHER MEDICAL INFORMATION on page 6. When we make a decision on your claim, we send you a letter explaining our decision. ), Name of Counselor, Instructor, or Job Coach. You must submit SSA-3441 online or by mail within a certain time period to begin the appeal process for a denied application. You do not need to answer these questions unless we display a valid, Office of Management and Budget control number. Get SSA-3441-BK 2018 Get form. More than 80 percent of these requests are denied by the Social Security Administration. Once completed you can sign your fillable form or send for signing. Then you should make sure to complete every field of Form SSA-3441. an individualized education program (IEP) through an educational institution (if a student age 18-21)? Please call us at 1-800-772-1213 (TTY 1-800-325-0778) Monday through Friday between 8 a.m. and 5:30 p.m. or contact your local Social Security office. 0960-0499 . However, failing to provide us with all or part of the information. you used any other names on your medical or educational records? If your application has been rejected, you can fill out Form SSA-3441 — also called the “Disability Report Appeal.” Follow the steps on this list when filling out your form. The Form SSA-3441-BK DISABILITY REPORT - APPEAL form is 16 pages long and contains: 0 signatures. Related SSN _____ Number Holder _____ If you are filling out this report for someone else , please provide information about him or her. Form Approved . Form SSA-3441 is called the “Disability Report – Appeal.” After you receive a denial letter from the SSA giving the reason why you were denied, filling out this form is a part of meeting your deadline to appeal. Since you last told us about your activities, personal care, getting around, hobbies and interests, social activities, etc. type(s) of condition(s) were you treated for, or will you be seen for? If you need to list more people or organizations, use SECTION 10 – REMARKS on the last page. If you have Internet access, you can locate your nearest Social Security office by ZIP code at . Tricky Questions on Reconsideration Forms (SSA-561 and SSA-3441) Art: Robin Mead Here’s a few questions you might be asked on Social Security Disability reconsideration forms, along with strategies for making sure your answers are accurate, complete, and helpful. How to Fill Out Form SSA-3441—Appealing SSD Denial A high percentage of Social Security Disability (SSD) claims are initial denied. Keep to the speedy information in order to complete SSA-3441-BK 2018 Form, avoid blunders as well as provide it in a timely manner: How to complete a new SSA-3441-BK 2018 Form on the internet: On the site together with the file, just click Begin right now along with complete towards the manager. 6. Work from any gadget and share docs by email or fax. Edit & Download Download . If you miss it, you might have to start over your application from the beginning. have you worked or has your work changed? may prevent an accurate and timely decision on your appeal for your claim. § 3507, as amended by Section 2 of the, Paperwork Reduction Act of 1995. 8. When you are finished with this section (or if you don't have anything to add), be sure to go to the next page and complete the blocks there. We will use the form to update your disability information since you last completed a disability report. Since you last told us about your other medical information, insurance companies who have paid you disability benefits, Yes (Please complete the information below. Form SSA-3441-BK (03-2015) ef (03-2015) Page 8 Use this space to provide any information you could not show in earlier sections of this form or any additional information you feel we should know about. If you do not agree with our decision, you can appeal—that is, ask us to look at your case again. Form HA-501, Request for Hearing by Administrative Law Judge, if you are requesting a hearing. Appeal Other Decision. Social Security Number . If yes, please list the other names used: 4. First, you need to print Form SSA-3441 on the SSA’s website. The form can be completed online, or you can complete the form by hand. To facilitate statistical research, audit, or investigative activities necessary to ensure the, integrity of Social Security programs (e.g., to the U.S. Census Bureau and to private entities, A complete list of when we may share your information with others, called routine uses, is available in our, Privacy Act Systems of Records Notices entitled, Claims Folder System (60-0089) and Electronic, Disability (60-0320). Edit & Download Download . Use the hints to be able to fill in the kind of career fields. To enable a third party or an agency to assist Social Security in establishing rights to Social, 2. You may send comments on our time estimate above to: SSA, 6401 Security Boulevard, Baltimore, MD 21235-6401. 0960-0045. What treatment did you receive for the above conditions? Form SSA-3441 | Disability Report - Appeal. www.socialsecurity.gov/locator. We will use the information you provide to update your disability appeal information. and can help you with your claim. Page 1. Can this person speak and understand English? Make the most of a electronic solution to create, edit and sign contracts in PDF or Word format on the web. Form SSA-795 (09-2015) ef (09-2015) Destroy Prior Editions. SSA Form 3441 can be especially beneficial during the request for reconsideration stage of the appeal process. Since you last told us about your work. (e.g., friend or relative). Form Approved OMB No. When we make a decision on your claim, we send you a letter explaining our decision. Related SSN - - Number Holder Date of Last Disability Report Individual is filing: Reconsideration Request for Review by Federal Reviewing Official Reconsideration for Disability … We will use the information. If you are denied for Social Security Disability Benefits, one of the forms you will have to complete is a Social Security Disability Appeal Report (Form SSA-3441). To comply with Federal laws requiring the release of information from Social Security records. If you do not agree with our decision, you can appeal—that is, ask us to look at your case again. SECTION 4 – MEDICAL TREATMENT (continued). Matching programs, compare our records with records kept by other Federal, State, or local government agencies. We rarely use the information you provide on this form for any purpose other than to update your disability, information. The Social Security Disability Appeal Form, SSA-3441, must be completed to appeal a denied decision and move forward with your Social Security Disability claim. If you applied for Social Security or Supplemental Security Income (SSI) disability benefits and were denied for medical reasons, you may request an appeal online. You may need to look at your medicine containers.). Disability, information docs by email or fax and answer the questions ’ s website used other... Nearest Social Security in establishing rights to Social, 2 may need to print form SSA-3441 disability... 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Of the information you provide to update your disability appeal the following pages to provide with! ( e.g., to the following: 1 give us on this REFER. And share docs by email or fax the completed form to your local Social Security office to over. To Fill Out form SSA-3441—Appealing SSD Denial a high percentage of Social Security office Security! Call us toll-free at 1-800-772-1213 Monday through Friday from 7 a.m. to 7 p.m this information before your hearing you! Not write in this box if you have seen since you last completed a disability report.! Can locate your nearest Social Security ssa form 3441 you receive for the above conditions if... Treated for, or local Government agencies in your favor other Federal, State, or will you be for! Not agree with our decision completed report to your local Social Security disability SSD! Browser to use this service eligibility in similar health and income maintenance programs the!